While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

The client's comfort level is increased when the nurse breaks eye contact to type notes into the record.

Completing the electronic record during an interview is a legal obligation of the examining nurse.

The nurse has limited ability to observe nonverbal communication while entering the assessment electronically.

The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

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Correct Answer is A

Explanation

Choice A reason: This is the most important instruction because lowering the bed reduces the risk of injury to both the client and the UAP. It also makes it easier for the UAP to use proper body mechanics and leverage when assisting the client to move up in bed.

Choice B reason: This is not the most important instruction because encouraging the client to eat all of the meals that are sent is not directly related to repositioning the client. While adequate nutrition is important for wound healing and recovery, the nurse should assess the client's appetite, dietary needs, and preferences before instructing the UAP to encourage the client to eat.

Choice C reason: This is also not the most important instruction because offering fruit juice at least twice during both the day and evening shifts is not directly related to repositioning the client. While adequate hydration is important for preventing constipation and promoting circulation, the nurse should consider the client's fluid status, blood sugar levels, and potential interactions with medications before instructing the UAP to offer fruit juice.

Choice D reason: This is another incorrect instruction because having the client hold a pillow over the abdomen to cough and deep breathe is not directly related to repositioning the client. While coughing and deep breathing are important for preventing respiratory complications and promoting oxygenation, the nurse should instruct the client to perform these exercises at regular intervals, not only when repositioning.

A. Walks with the arms fully extended. B. Fits the crutch 2 finger widths from axilla. C. Avoids adjusting the height of the hand grips. D. Holds the crutch 6 inches (15 cm) to the side.

Correct Answer is B

Explanation

Choice A reason: This is an incorrect action as it indicates poor posture and balance. The client should walk with the elbows slightly flexed and the shoulders relaxed.

Choice B reason: This is the correct action as it ensures proper fit and comfort of the crutch. The client should fit the crutch 2 finger widths from the axilla to prevent nerve damage and pressure ulcers.

Choice C reason: This is an incorrect action as it may cause pain and injury to the wrists and hands. The client should adjust the height of the hand grips to allow a 30-degree bend at the elbow.

Choice D reason: This is an incorrect action as it may cause instability and falls. The client should hold the crutch 4 to 6 inches (10 to 15 cm) in front and to the side of the foot.

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While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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